Please read and make your selections below to indicate your consent.

PFIZER PAC SUPPORT OPT-IN

When you opt-in for Pfizer Patient Access Coordinator (PAC) support you will be contacted by a Pfizer PAC who can help you understand your insurance benefits and navigate the process to access your prescribed medication. Pfizer PACs are field-based employees of Pfizer Rare Disease and, if you choose, will help answer questions you may have about accessing the medication prescribed by your Healthcare Provider. Pfizer PACs are familiar with access and reimbursement requirements, and the Pfizer PAC assigned to you serves as a resource for you on your journey to starting therapy. Working with a Pfizer PAC is optional. By checking this box/signing this form, I request Pfizer PAC support and agree to receive telephonic communications from the Pfizer PAC assigned to my case as described above. I understand that my consent is not required or a condition of purchasing any Pfizer goods or services. I understand that I can opt-out of support from and communications with the Pfizer PAC at any time by informing my assigned PAC that I no longer wish to communicate with them. I understand that this form will remain in effect for one year (ie, 1 year from the date of my signature) unless I opt-out of support from and communications with the Pfizer PAC at any time by informing my assigned PAC that I no longer wish to communicate with them.

Patient authorization date:

yyyy-MM-ddTHH:mm:ss

Please review your Pfizer PAC support opt-in. You must indicate what prescription you have AND check the box requesting Pfizer PAC support.